<?php
session_start ();
$_SESSION ['pathway'] = '..';
$_SESSION ['pathway_js'] = '/clinique';
include ($_SESSION ['pathway'] . "/header.php");

?><a href="<?php echo $_SESSION['pathway']; ?>/index.php">Start</a>
>
<a href="<?php echo $_SESSION['pathway']; ?>/start.php">Home</a>
> Activity Form
<?php

$score = 0;
if (! isset ( $_SESSION ['id'] ) or $_SESSION ['acces_genetique'] < 1) {
	echo "<table class='principale'><tr><td>Session expired</td></tr>";
	echo "<tr><td><a href='" . $_SESSION ['pathway'] . "/index.php'>Start</a></td></tr></table>";
} else {
	?>

<form name='frm_form_activite'
	action="<?php echo $_SESSION['pathway']; ?>/start.php?from=form_activite"
	method='post'>

	<table class='principale'>

		<tr>
			<td colspan="2"><h2>form D&apos;ACTIVIT&Eacute;</h2></td>
		</tr>

		<tr>
			<td><br /> <br /> <br /></td>
		</tr>
		<tr>
	<?php
	
	$today = getdate ();
	$current_date = $today ['year'] . '-' . $today ['mon'] . '-' . $today ['mday'];
	?>
	<td><br /> <b>Date : </b></td>
			<td><br /> <input type="text" style="width: 100px;" name="date"
				value="<?php echo $current_date; ?>" />&#40;yyyy&#45;mm&#45;dd&#41;</td>
			<td><br />NIP : <input type="text" style="width: 150px;" name="nip" /></td>
		</tr>
		<tr>
			<td></td>
			<td>Neurologist : <input type="text" style="width: 100px;"
				name="neurologist" value='' /></td>
			<td>User : <input type="text" style="width: 100px;" name="user"
				readonly='readonly'
				value="<?php echo strtoupper($_SESSION['id']); ?>" /></td>
		</tr>
		<tr>
			<td><br /> <b>Site : </b></td>
			<td><br /> <label><input type="radio" name="site"
					value="Salpetriere Ataxies/PS" />Salp&ecirc;tri&egrave;re
					Ataxies/PS</label><br /> <label><input type="radio" name="site"
					value="Trousseau" />Trousseau</label><br /> <label><input
					type="radio" name="site" value="Salpetriere mouvements anormaux" />Salp&ecirc;tri&egrave;re
					mouvements anormaux</label></td>
		</tr>

		<tr>
			<td><br /> <b>Patient : </b></td>
			<td><br />Sexe : <label><input type="radio" name="sex" value="female" />Femme</label><label><input
					type="radio" name="sex" value="male" />Homme</label></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Date de naissance : <input type="text"
				style="width: 100px;" name="birthdate" />&#40;yyyy&#45;mm&#45;dd&#41;
			</td>
		</tr>
		<tr>
			<td><br /> <b>Origine g&eacute;ographique : </b></td>
			<td><br /> <label><input type="radio" name="location"
					value="Ile de France" />Ile de France</label><br /> <label><input
					type="radio" name="location" value="France, hors IDF" />France,
					hors IDF</label><br /> <label><input type="radio" name="location"
					value="Union Europeenne" />Union Europ&eacute;enne</label><br /> <label><input
					type="radio" name="location" value="Hors UE" />Hors UE</label><br />
			
			<td><br />Si hors Ile de France, pr&eacute;ciser (d&eacute;partement
				ou pays) : <input type="text" style="width: 100px;"
				name="location_other" /></td>
		</tr>

		<tr>
			<td colspan="4"><br />
				<hr width="1000"></td>
		</tr>

		<tr>
			<td><b>DIAGNOSTIC</b></td>
		</tr>
		<tr>
			<td><br /> <b>Maladie concern&eacute;e <br />(suspect&eacute;e ou
					affirm&eacute;e) :
			</b></td>
			<td><br /> <input type="checkbox" name="diagnostic[]" value="Ataxie">Ataxie<br />
				<input type="checkbox" name="diagnostic[]" value="Choree (non HD)">Chor&eacute;e
				(non HD)<br /> <input type="checkbox" name="diagnostic[]"
				value="Dystonie">Dystonie<br /> <input type="checkbox"
				name="diagnostic[]" value="Encephalopathie">Enc&eacute;phalopathie<br />
				<input type="checkbox" name="diagnostic[]" value="Leucodystrophie">Leucodystrophie
				<br /> <input type="checkbox" name="diagnostic[]"
				value="Mouvements anormaux paroxystiques">Mouvements anormaux
				paroxystiques <br /> <input type="checkbox" name="diagnostic[]"
				value="Myoclonies">Myoclonies <br /> <input type="checkbox"
				name="diagnostic[]" value="Paraplegie spastique">Parapl&eacute;gie
				spastique</td>
			<td><br />Autre : <input type="text" style="width: 100px;"
				name="diagnostic_other" /></td>
		</tr>

		<tr>
			<td><br /> <b>Diagnostic g&eacute;n&eacute;tique connu : </b></td>
			<td><br /> <label><input type="radio" name="diagnostic_genetique"
					onchange='toggleDiagnosticConnu(this.value)' value="oui" />Oui</label><br />
				<label><input type="radio" name="diagnostic_genetique"
					onchange='toggleDiagnosticConnu(this.value)' value="non" />Non</label><br /></td>
			<td><br />
				<div id='div_diagnostic_genetique' style='display: none;'>
					Specifiez :<input type="text" style="width: 100px;"
						name="diagnostic_genetique_specify" />
				</div></td>
		</tr>

		<tr>
			<td><br /> <b>Diagnostic clinique complet : </b></td>
			<td colspan="3"><br /> <textarea cols="80" name="diagnostic_complet"></textarea></td>
		</tr>

		<tr>
			<td><br /> <b>Mode de transmission : </b></td>
			<td colspan="3">
				<table class='normale'>
					<tr>
						<td><br /> <input type="checkbox" name="mode[]" value="AD">AD<br />
							<input type="checkbox" name="mode[]" value="AR">AR</td>
						<td><br /> <input type="checkbox" name="mode[]" value="Recessif">R&eacute;cessif<br />
							<input type="checkbox" name="mode[]" value="Sporadique">Sporadique<br /></td>
						<td><br /> <input type="checkbox" name="mode[]"
							value="Sp. avec censure">Sp. avec censure<br /> <input
							type="checkbox" name="mode[]" value="Sp. sans censure">Sp. sans
							censure<br /></td>
						<td><br /> <input type="checkbox" name="mode[]" value="X linked">Li&eacute;
							&agrave; l&apos;X<br /> Autre : <input type="text"
							style="width: 100px;" name="mode_other" /></td>
					</tr>
				</table>
			</td>
		</tr>



		<tr>
			<td colspan="4"><br />
				<hr width="1000"></td>
		</tr>

		<tr>
			<td><b>PRISE EN CHARGE ET ORIENTATION</b></td>
		</tr>

		<tr>
			<td></td>
			<td><br /> <label><input type="radio" name="nouveau_patient"
					value="Patient deja connu du Centre" />Patient d&eacute;j&agrave;
					connu du Centre</label><br /> <label><input type="radio"
					name="nouveau_patient" value="Nouveau patient" />Nouveau patient</label><br /></td>
		</tr>

		<tr>
			<td><br /> <b>Type de prise en charge <br /> ou avis donn&eacute; :
			</b></td>
			<td><br /> <label><input type="radio" name="prise_en_charge"
					value="Consultation" />Consultation</label><br /> <label><input
					type="radio" name="prise_en_charge" value="HDJ" />HDJ</label><br />
				<label><input type="radio" name="prise_en_charge" value="CMD" />CMD</label><br />
				<label><input type="radio" name="prise_en_charge"
					value="Hospitalisation complete" />Hospitalisation compl&egrave;te</label><br />
				<label><input type="radio" name="prise_en_charge"
					value="Avis donne (sur dossier, par courrier, par telephone, par mail)" />Avis
					donn&eacute; (sur dossier, par courrier , <br />par
					t&eacute;l&eacute;phone, par mail)</label><br /></td>
		</tr>

		<tr>
			<td><br /> <b>Contexte de la prise en charge/avis, <br /> patient
					adress&eacute; par :
			</b></td>
			<td><br /> <label><input type="radio" name="contexte_prise_en_charge"
					value="Suivi par le centre" />Suivi par le centre</label><br /> <label><input
					type="radio" name="contexte_prise_en_charge"
					value="Un generaliste (1er avis)" />Un g&eacute;n&eacute;raliste
					(1er avis)</label><br /> <label><input type="radio"
					name="contexte_prise_en_charge"
					value="Un specialiste de ville (2nd avis)" />Un sp&eacute;cialiste
					de ville (2nd avis)</label><br /> <label><input type="radio"
					name="contexte_prise_en_charge"
					value="Un specialiste hospitalier (2nd avis)" />Un
					sp&eacute;cialiste hospitalier (2nd avis)</label><br /> <label><input
					type="radio" name="contexte_prise_en_charge"
					value="Une association (1er avis)" />Une association (1er avis)</label><br />
				<label><input type="radio" name="contexte_prise_en_charge"
					value="Demarche personnelle (1er avis)" />D&eacute;marche
					personnelle (1er avis)</label><br /></td>
		</tr>

		<tr>
			<td><br /> <b>Orientation personnalis&eacute;e : </b></td>
			<td><br /> <input type="checkbox" name="orientation_personnalisee[]"
				value="Orthophoniste">Orthophoniste<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Kine">Kin&eacute;<br /> <input
				type="checkbox" name="orientation_personnalisee[]"
				value="Psychomotricien">Psychomotricien<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Dieteticien">Di&eacute;t&eacute;ticien<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="Psychologue">Psychologue <br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Psychiatre">Psychiatre <br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="Toxines">Toxines <br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Neuropsychologue">Neuropsychologue<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="Medecin traitant">M&eacute;decin traitant<br /> <input
				type="checkbox" name="orientation_personnalisee[]" value="MPR">MPR<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="Stimulation">Stimulation<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="EMG">EMG<br /> <input
				type="checkbox" name="orientation_personnalisee[]"
				value="IRM cerebrale">IRM c&eacute;r&eacute;brale<br /></td>
			<td><br /> <input type="checkbox" name="orientation_personnalisee[]"
				value="MOC">MOC<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Hospitalisation">Hospitalisation<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="CMD">CMD<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Enreg. mvts anormaux">Enreg.
				mvts anormaux<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Centre de compétence">Centre
				de comp&eacute;tence<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Protocole">Protocole<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="ATU">ATU<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Assistante sociale">Assistante
				sociale<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Recherche genetique">Recherche
				g&eacute;n&eacute;tique<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Diagnostic genetique">Diagnostic
				g&eacute;n&eacute;tique<br /> <input type="checkbox"
				name="orientation_personnalisee[]" value="Metabolique">M&eacute;tabolique<br />
				<input type="checkbox" name="orientation_personnalisee[]"
				value="Biologie courante">Biologie courante<br />
			
			<td><br />Autre, pr&eacute;ciser : <input type="text"
				style="width: 100px;" name="orientation_personnalisee_other" /></td>
		</tr>


		<tr>
			<td><br /> <br /> <br /> <input type='submit' value='Send'
				onclick="alert('Thank you');"></td>
		</tr>



	</table>
</form>



<?php
}
include ($_SESSION ['pathway'] . "/footer.php");
?>
